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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005602
Report Date: 12/09/2021
Date Signed: 12/09/2021 11:53:17 AM

Document Has Been Signed on 12/09/2021 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FLAXMAN, CAROLINA S.FACILITY NUMBER:
214005602
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/09/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Applicant, Carolina FlaxmanTIME COMPLETED:
12:05 PM
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On December 9th, 2021 at 10:30 am Licensing Program Analyst (LPA) Kassandra Medrano met with applicant, Carolina Flaxman. Applicant lives in a 2 bedroom, two bath condominium. Hours of operation will be Monday to Friday 8AM to 5PM. Child care will be provided in areas: Family Room, Backyard, Kitchen, Bedroom #1 and #2, and Bathroom #2. Kitchen will only be used to pass through to yard. Bedrooms are only planned for napping. Off limit areas: Bathroom #1, Closets #1 and #2, and Side deck. All off limits areas are made inaccessible to children. LPA inspected the entire home with the applicant for health and safety hazards. The house has proper temperature and ventilation. All toxic or dangerous materials are stored in cabinets with child protective locks installed making them inaccessible. There is a fire place located in the home, and it is properly barricaded. The house has a working telephone, fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Applicant has first aid supplies available. There are a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. Applicant was informed that time outs cannot be any longer than one minute per age of the child and cannot exceed five minutes. Applicant states that she will only be using communication and redirection for children as forms discipline. She states she will only do positive forms of discipline, she will also be communicating with parents expectations. LPA informed the applicant that emergency drills will be conducted at least once every six months and drills must be logged. Applicant's First Aid/CPR certificate is current and expires 8/2023. Applicant has been made aware that they need required postings in the home. Applicant is planning to apply for insurance, but does not currently have insurance. LPA discussed facility ratios and capacity's with the applicant. The applicant was reminded there are no walkers, exersaucers, jumpers, bouncers and any similar items to be used for children in care and shall be made inaccessible. Licensee is advised all adults, 18 years and older living in the home, Helper, or assistant must have criminal record clearance and must be associated to the facility by submitting an LIC 9182 with copy of CDL or Ca. ID prior to having any contact with the children in care and failure to do so could result in an immediate civil penalty of $100.00 each day.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FLAXMAN, CAROLINA S.
FACILITY NUMBER: 214005602
VISIT DATE: 12/09/2021
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During inspection,
-Incidental Medical Services (IMS) policy was discussed.
-Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
-Licensee was reminded about Mandated Reporter Training available on CCLD website
(www.ccld.ca.gov or www.mandatedreporterca.com).
-Licensee was given information regarding ‘Safe Sleep’ practices.

Licensee to send documentation of proper postings.

Capacity limits of a Small License has been reviewed with Licensee.

Small Family Child Care License is approved and will be effective as of today, 12/09/2021.

This report will be kept in the facility file and will be made available for public review upon request. Desk duty is available Monday - Friday, 8:00a.m.- 5:00p.m. (650) 266-8800.
Copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (650) 266-8800.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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